Forms

New Patient Registration Packet

If you are a new patient of ours, we welcome you to fill out the necessary paperwork ahead of your appointment. (This really speeds up your check-in at the time of your appointment and can help you see your doctor even faster!)

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PATIENT CHECKLIST

Need a worksheet to track your medications or make notes for your doctor?

Download this handy patient checklist and bring it with you before seeing your doctor at your next appointment!
(English Worksheet)
(Spanish Worksheet)

Sliding Fee Application

We are so happy to offer a sliding fee discount program to eligible individuals based on the patient’s ability to pay.  Ability to pay is determined by the household size and annual income relative to a discount schedule based on federal poverty income guidelines.

If you would like to apply, please fill out the following application:

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3rd Party Release of Health Information

If you would like a 3rd party to be given the permission/ability to discuss your healthcare with our staff, please fill out the following form. (Note: If you are a new patient, this form is already included in your registration packet.)

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Authorization to Release Health Information

Unlike the 3rd party release form, the Authorization to Release Health Information form is a form that releases health information from your medical record; whether that be to someone in your family or another medical institution. (Note: if you are a new patient, this is not included in your patient registration packet.)

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